doi:10.1111/j.1744-1609.2010.00177.

x Int J Evid Based Healthc 2010; 8: 256258

EVIDENCE SYNTHESIS

Effectiveness of voice rehabilitation on vocalisation in

postlaryngectomy patients: a systematic review jbr_177 256..258

Shuxin Xi MSN, RN
Eye & ENT Hospital, Fudan University and The Fudan Evidence Based Nursing Center: A Collaborating Centre of the Joanna Briggs
Institute, Shanghai, China

Abstract
Background Laryngeal cancer is one of the most common malignant neoplasia of the head and neck. Its
incidence has been increasing steadily all over the world. Many patients will undergo total laryngectomy with or
without radical neck dissection after being diagnosed. After this surgery, normal speech is lost, and a permanent
stoma in the middle of the neck is left. Therefore, voice rehabilitation is one of the most difficult challenges that these
patients must overcome. In order to support the patients, otolaryngologists, nursing specialists and speech patholo-
gists have explored several different methods for voice rehabilitation. Variations exist on the approaches of rehabili-
tation and indicators selected to measure the effectiveness. There is a need to undertake a systematic review to
provide a plan of care and ascertain the effectiveness regarding different voice rehabilitation programs for postla-
ryngectomy patients.
Review objective To critically analyse the literature and present the best available evidence related to the
effectiveness of voice rehabilitation program on postlaryngectomy patients.
Search strategy A three-step search strategy was utilised. An initial limited search of MEDLINE and CINAHL
databases was undertaken followed by an analysis of the text words contained in the title and abstract to identify the
optimal index terms. A second extensive search using all identified key words and index terms was then undertaken.
Third, the reference list and bibliographies of all identified reports and articles were searched for additional studies.
The measurement index included voice intelligibility, volume, clarity, quality of voice, patients satisfaction, quality
of life, etc. The search included reports in English and Chinese.
Selection criteria The review considered any randomised controlled trials that addressed voice rehabilitation
methods in postlaryngectomy patients. In the absence of randomised controlled trials, other quantitative research
designs, such as non-randomised controlled trials, cohort studies and case-controlled studies, were considered for
inclusion.
Data collection and analysis Full copies of articles considered to meet the inclusion criteria were obtained for
critical appraisal by two reviewers using the CASP (Critical Appraisal Skills Program) and McMaster scales. We utilised
the 60% fulfilling of the evaluation scale items as the cut-off point and articles with a quality score less than 60% were
excluded. Details of eligible trials were extracted and summarised by two reviewers independently using standard-
ised data extraction tools developed by the Joanna Briggs Institute.
Results Twenty-two articles were included in the review (Appendix I). Different voice rehabilitation methods for
laryngectomees were investigated in the included studies including oesophageal voice, electrolarynx voice and
surgical voice restoration. One cohort studies, five prospective studies, five retrospective studies and 11 descriptive
studies were included. Because of the heterogeneity of included studies, meta-analysis was not possible. There-
fore, the results were presented in narrative summary. The following main findings were identified:
1 At present, oesophageal speech, electrolarynx and tracheoesophageal were the commonly used voice rehabili-
tation methods with total laryngectomy patients.
2 Among these three methods, the success rate of electrolarynx and tracheoesophageal is much higher than
oesophageal speech.
3 The intelligibility and speech quality of electrolarynx was lower than tracheoesophageal.

Correspondence: Ms Shuxin Xi, 83 Fenyang Road, Eye & ENT

Hospital, Fudan University, 200031 Shanghai, P.R. China.
Email: shuxinxi71@126.com

2010 The Author

International Journal of Evidence-Based Healthcare 2010 The Joanna Briggs Institute
 Voice rehabilitation on vocalisation in postlaryngectomy patients 257

4 Patient satisfaction and self-assessed quality of life was better in tracheoesophageal group.
5 The objective index was similar between excellent tracheoesophageal and oesophageal speech patients.
Conclusion
1 Electrolarynx is the easiest vocal rehabilitation method for total laryngectomy patients to use as it requires little
training and does not limit the patients. But patients satisfaction was lower because of the mechanical voice and
noise.
2 Oesophageal speech is the hardest vocal rehabilitation method to learn. It needs a long period of time to practise
and requires the patient to be in good physical condition and to be relatively young. The success rate was
relatively lower; however, it is the most commonly used rehabilitation method in developing countries because of
low cost.
3 Tracheoesophageal is the most commonly used voice rehabilitation method in developed countries. It is a surgical
method that could be performed as either a primary procedure or secondary procedure. Reported patient quality
of life and satisfaction following tracheoesophageal were the best; however, there are complications and the
frequent replacement of the prostheses is an important problem yet to be solved.
Implication for practice
1 Voice rehabilitation after total laryngectomy is an immediate and long-term problem that patients and health
worker must face.
2 Healthcare workers should understand the advantages and disadvantages of each voice rehabilitation method in
detail to assist people with total laryngectomy to make the most appropriate decision in regard to rehabilitation
method taking into consideration their age, sex, physical condition, job, economic status and other context factors.
Implication for research
1 Further high-quality studies comparing the effectiveness of oesophageal speech, electrolarynx and tracheoesoph-
ageal vocal rehabilitation methods are needed, especially with the subjective and objective outcome index
concurrently.
2 Further investigation is required to identify strategies to decrease the complications of tracheoesophageal and
reduce frequency of required tracheoesophageal replacement.
3 More research is needed in the context of developing countries where healthcare resources may be limited.
Key words: laryngectomy, systematic review, vocalisation, voice rehabilitation.

Translation to practice 4 Otolaryngologists, speech pathologists and/or clinical

When healthcare workers provide care to a laryngeal cancer
patient who undergo total laryngectomy, suggestions are:
1 Otolaryngologists should educate the patient and/or their
families/caregivers in detail of the process and implica-
tions of total laryngectomy.
2 Speech pathologists or laryngological clinical nursing spe-
cialists should explain to the patient the different alter-
native communication methods such as oesophageal
speech, electrolarynx and tracheoesophageal after total
laryngectomy. The advantages, disadvantages and impli-
cations for each alaryngeal speech should be clearly
explained to the patients and their families/caregivers.
Various methods of communication (e.g. demonstration
or use of video) should be used as appropriate to improve
understanding.
3 Speech pathologists or laryngological clinical nursing spe-
cialists should assist patients to make informed personal
decisions to select the most appropriate voice rehabilita-
tion method for them with consideration of their age, sex,
physical condition, employment and economic status.
nursing specialists should work together as a team to help
total laryngectomy patients achieve the best results with
their preferred voice rehabilitation method. However, if
the selected method does not result in positive outcomes,
team workers should assist patients to select an alternative
method to achieve successful communication.
Appendix I
Included studies
1. Koike M, Kobayashi N, Hirose H, Hara Y. Speech rehabilitation
after total laryngectomy. Acta Otolaryngol 2002; 122 (Suppl.
547): 10712.
2. Aust MR, McCaffrey TV. Early speech results with the Provox
prosthesis after laryngectomy. Arch Otolaryngol Head Neck Surg
1997; 123: 9668.
3. Perry AR, Shaw MA, Cotton S. An evaluation of functional
outcomes (speech, swallowing) in patients attending speech
pathology after head and neck cancer treatments(s): results and
analysis at 12 months post-intervention. J Laryngol Otol 2003;
117: 36881.

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258 S Xi
4. Cornu AS, Vlantis AC, Elliot H et al. Voice rehabilitation after
laryngectomy with the Provox voice prosthesis in South Africa.
J Laryngol Otol 2003; 117: 569.
5. Chone CT, Spina AL, Crespo AN, Gripp FM. Speech rehabilita-
tion after total laryngectomy:long-term results with indwelling
voice prosthesis Blom-Singer. Rev Bras Otorhinolaryngol 2005;
71: 5049.
6. Geraghty JA, Wenig BL, Smith BE, Portugal LG. Long-term
follow-up of tracheoesophageal puncture results. Ann Otol
Rhinol Laryngol 1996; 105: 5013.
7. Makitie AA, Niemensivu R, Juvas A et al. Postlaryngectomy voice
restoration using a voice prosthesis: a single institutions ten-
year experience. Ann Otol Rhinol Laryngol 2003; 112: 1007
10.
8. Van Den Hoogen FJA, Van Den Berg RJH, Oudes MJ et al. A
prospective study of speech and voice rehabilitation after total
laryngectomy with the low-resistance Groningen, Nijdam and
Provox voice prostheses. Clin Otolaryngol Allied Sci 1998; 23:
42531.
9. Op de Coul BMR, Hilgers FJM, Balm AJM et al. A decade of
postlaryngectomy vocal rehabilitation in 318 patients: a single
institutions experience with consistent application of Provox
indwelling voice prostheses. Arch Otolaryngol Head Neck Surg
2000; 126: 13208.
10. Meltzner GS, Hillman RE. Impact of aberrant acoustic properties
on the perception of sound quality in electrolarynx speech.
J Speech Lang Hear Res 2005; 48: 76679.
11. Searl JP, Carpenter MA, Banta CL. Intelligibility of stops and
fricatives in tracheoesophageal speech. J Commun Disord 2001;
34: 30521.
12. Smith LF, Calhoun KH. Intelligibility of tracheoesophageal
speech among nave listeners. South Med J 1994; 87: 3335.
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13. Eadie TL, Doyle PC. Auditory-perceptual scaling and quality of
life in tracheoesophageal speakers. Laryngoscope 2004; 114:
7539.
14. Kazi RSA, De Cordova J, Clarke PHK et al. A new self-
administered questionnaire to determine patient experience
with voice prostheses (Blom-Singer Valves). J Postgrad Med
2005; 51: 2538.
15. Caterina F, Bengt B. Health-related quality of life in patients with
laryngeal cancer: a post-treatment comparison of different
modes of communication. Laryngoscope 2001; 111: 91823.
16. Ward EC, Koh SK, Frisby J et al. Differential modes of alaryngeal
communication and long-term voice outcomes following
pharyngolaryngectomy and laryngectomy. Folia Phoniatr Logop
2003; 55: 3949.
17. Cervera T, Miralles JL, Gonzalez-Alvarez J. Aoustic analysis of
Spanish vowels produced by laryngectomized subjects. J Speech
Lang Hear Res 2001; 44: 98896.
18. Eadie TL, Doyle PC. Quality of life in male TE speakers. J Rehabil
Res Dev 2005; 42: 11524.
19. Schuster M, Lohscheller J, Kummer P et al. Quality of life in
laryngectomees after prosthetic voice restoration. Folia Phoniatr
Logop 2003; 55: 21119.
20. Clements KS, Christopher HR, Hadi S et al. Communication
after laryngectomy: an assessment of patients satisfaction. Arch
Otolaryngol Head Neck Surg 1997; 123: 4936.
21. Bellandese MH, Lerman JW. An acoustic analysis of excellent
female esophageal, tracheoesophageal, and laryngeal speakers.
J Speech Lang Hear Res 2001; 44: 131520.
22. Staffier A, Mostafa BE, Varghese BT et al. Cost of tracheoesoph-
ageal prostheses in developing countries: facing the problem
from and internal perspective. Acta Otolaryngol 2006; 126:
49.